Bethanie Gwelup

72 Huntriss Road, GWELUP, WA, 6018

1. Accreditation decisionJul 10, 2025

   Following a site audit conducted on 30 August 2022 to 01 September 2022, the Commission made a decision on 06 February 2023 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 10 July 2025. The period of accreditation of the service will expire on 06 February 2026.

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2. Assessment Contact - SiteJul 19, 2023

   Prepared by G Cherry

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3. Assessment contact Performance ReportJun 21, 2023

   An assessment contact was conducted with this service on 20 June 2023 to 21 June 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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4. Accreditation decisionOct 19, 2022

   Following a site audit conducted on 30 August 2022 to 01 September 2022, the Commission made a decision on 19 October 2022 to re-accredit this service. The period of accreditation of the service will expire on 06 August 2025.

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5. Site AuditOct 19, 2022

   Prepared by Marek Dubovinsky

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   AI report insightsAI-extracted · qwen2.5:32b

   The performance report for Bethanie Gwelup indicates compliance with Standards 1, 4, and 5. However, non-compliance was found in Standards 2, 3, 6, 7, and 8 due to issues such as ineffective ongoing assessment and planning, inadequate personal care and clinical care management, poor handling of feedback and complaints, insufficient workforce competency, and ineffective risk management systems.

   math errorCompliant

   The assessor found that all requirements under the Consumer dignity and choice standard were met, indicating a compliant status.

   • Met 1(3)(a) — Consumers confirmed staff treat them with dignity and respect and were aware of their identity, culture and diversity.
   • Met 1(3)(b) — Policies and processes outline consumers’ right to respect and dignity. Consumers interviewed confirmed they are supported to exercise choice.
   • Met 1(3)(c) — Consumers were able to describe how the service recognises cultural safety and provides spiritual services.
   • Met 1(3)(d) — Staff described examples of supporting consumers to take risks for a better life.
   • Met 1(3)(e) — Consumers confirmed they have access to relevant information which is accurate and timely to support choice.
   • Met 1(3)(f) — Staff described how they maintain consumer privacy. Staff were observed maintaining consumer privacy and securing sensitive information.

   math errorNon-compliant

   The assessor found that the service was unable to demonstrate effective ongoing assessment and planning, particularly in identifying risks and reviewing care post-hospitalization or incidents.

   • Not met 2(3)(a) — For five sampled consumers, assessment and planning was not consistently undertaken to identify risks to their health and well-being.
   • Met 2(3)(b) — Consumers reported they have spoken to staff regarding end of life care. Records showed consumers are provided end-of-life care in accordance with an assessment and management plan.
   • Met 2(3)(c) — Systems and processes are in place to support consumer-centered assessment of needs, goals, and preferences.
   • Met 2(3)(d) — Care files demonstrated staff work with the consumer and/or representative to ensure care and service provision is in line with consumers’ needs and preferences.
   • Not met 2(3)(e) — For two sampled consumers, care and services were not reviewed regularly for effectiveness following hospitalization or incidents.

   Risks: Relevant risks to consumers' safety, health, and well-being were not identified and mitigation strategies were not implemented.

   Recommendations: Review policies and procedures to ensure risks associated with falls, skin integrity, choking, oral and dental, communication, changed behaviors, diabetes, pain, and nutrition and hydration are identified, assessed, and planned for.; Ensure staff are aware of and follow relevant policies and procedures in relation to assessment and review processes.

   math errorNon-compliant

   The assessor found that the service was unable to demonstrate safe and effective personal care and clinical care, particularly in managing pain, skin integrity, nutrition and hydration.

   • Not met 3(3)(a) — For five consumers, the service was not able to demonstrate effective management of personal care and clinical care needs.
   • Not met 3(3)(b) — The service failed to effectively manage high-impact or high-prevalence risks associated with falls, diabetes, and medication management for four consumers.
   • Met 3(3)(c) — One consumer was satisfied with processes to support end-of-life assessment and planning. The service has access to palliative care services.
   • Met 3(3)(d) — Deterioration or change of a consumer’s mental health, cognitive or physical function, capacity or condition is recognized and responded to in a timely manner for all sampled consumers.
   • Met 3(3)(e) — Information about the consumer's condition, needs, and preferences is documented and communicated within the organization.
   • Met 3(3)(f) — Processes support timely and appropriate referrals to individuals, other organizations, and providers of other care and services.
   • Met 3(3)(g) — Policies and procedures support antimicrobial stewardship and effective processes to prevent and control infections.

   Risks: Consumers experienced pain that was not effectively monitored or managed. Consumers' skin integrity and nutrition needs were not adequately addressed.

   Recommendations: Review relevant policies and procedures in relation to identifying and managing consumers in relation to clinical care needs associated with pain, skin integrity, nutrition and hydration.; Ensure staff are aware of and follow relevant policies and procedures in relation to the delivery of safe and effective personal care and clinical care.

   math errorCompliant

   The assessor found that all requirements under the Services and supports for daily living standard were met, indicating a compliant status.

   • Met 4(3)(a) — Consumers said they received safe and effective services and supports for daily living to support their quality of life.
   • Met 4(3)(b) — Care planning documentation showed consumers had their emotional, spiritual, and psychological well-being care and service needs identified and documented.
   • Met 4(3)(c) — Consumers said they are assisted with daily living activities that support them to pursue their interests and take part in the community and social activities.
   • Met 4(3)(d) — Information about the consumer’s condition, needs, and preferences is reflected in consumer care plans, assessments, lifestyle activities plan, and progress notes.
   • Met 4(3)(e) — Staff could describe how they refer consumers to external organizations and use volunteers to help supplement the lifestyle program.
   • Met 4(3)(f) — Most consumers said they were satisfied with the variety of quantity of meals. Documentation showed consumers have their preferences and relevant dietary information recorded to support service delivery.
   • Met 4(3)(g) — Observations of the meals service indicated a positive dining experience.

   math errorCompliant

   The assessor found that all requirements under the Organisation’s service environment standard were met, indicating a compliant status.

   • Met 5(3)(a) — Consumers said they find the service environment welcoming and easy to navigate.
   • Met 5(3)(b) — Consumer rooms were observed to be personalized. Maintenance and cleaning schedules ensure the environment is safe, clean, and well maintained.
   • Met 5(3)(c) — Furniture, fittings, and equipment were observed to be safe, clean, well-maintained, and suitable for consumers.

   math errorNon-compliant

   The assessor found that the service was unable to demonstrate appropriate action in response to complaints or use an open disclosure process when things go wrong.

   • Met 6(3)(a) — Consumers said they are encouraged and supported to provide feedback.
   • Met 6(3)(b) — A range of pamphlets were observed to be available to consumers to support feedback mechanisms and advocacy services.
   • Not met 6(3)(c) — Appropriate action was not taken in response to complaints for two consumers. Management was unaware of the complaint.
   • Not met 6(3)(d) — Feedback and complaints are not reviewed or used to improve the quality of care and services.

   Risks: Consumers' feedback is not effectively addressed leading to dissatisfaction with service delivery.

   Recommendations: Review relevant policies and procedures in relation to ensuring feedback and complaints are appropriately identified, addressed, and monitored for areas of improvement.; Ensure staff are aware of and follow relevant policies and procedures in relation to feedback and complaints handling and monitoring.

   math errorNon-compliant

   The assessor found that the service was unable to demonstrate that the workforce is competent and has the knowledge to effectively perform their roles.

   • Met 7(3)(a) — Processes support the planning and management of the workforce to ensure the number of personnel is sufficient to meet the care needs of consumers.
   • Met 7(3)(b) — Workforce interactions were observed to be kind, caring, and respectful of each consumer’s identity, culture, and diversity.
   • Not met 7(3)(c) — Deficits in staff competency for consumers identified in the Assessment Team's report included assessment and management of falls, pain, changed behaviors, medication, diabetes, incident analysis, implementing recommendations made by health specialists and service providers, and managing complaints and feedback.
   • Met 7(3)(d) — The workforce is recruited, trained, equipped, and supported to deliver the outcomes required by these standards.
   • Met 7(3)(e) — Regular assessment, monitoring, and review of the performance of each member of the workforce are undertaken.

   Risks: Staff competency issues in managing high-impact or high-prevalence risks associated with falls, diabetes, medication management, and implementing recommendations made by health specialists.

   Recommendations: Review monitoring processes and ensure staff are aware of their roles and responsibilities in relation to the management of falls, pain, changed behaviors, diabetes, medication, and implementing recommendations made by health specialists and service providers.; Ensure staff are aware and effectively use the incident management system to identify trends, analyze incidents, and report incidents in line with legislative requirements.

   math errorNon-compliant

   The assessor found that the service was unable to demonstrate effective risk management systems and practices specifically in relation to managing and preventing incidents.

   • Met 8(3)(a) — Consumers are engaged and supported in the development, delivery, and evaluation of care and services.
   • Met 8(3)(b) — The governing body promotes a culture of safe, inclusive, and quality care and services and is accountable for their delivery.
   • Met 8(3)(c) — Effective organization-wide governance systems relating to information management, continuous improvement, financial governance, workforce governance, regulatory compliance, feedback, and complaints are in place.
   • Not met 8(3)(d) — The service was not able to demonstrate effective risk management systems and practices specifically in relation to managing and preventing incidents, including the use of an incident management system.
   • Met 8(3)(e) — A clinical governance framework is in place which includes antimicrobial stewardship, minimising the use of restraint, and open disclosure.

   Risks: The service failed to recognize and report an incident as a type 1 within the required timeframe. Relevant actions including incident analysis were not undertaken.

   Recommendations: Review organisational risk management systems and practices specifically in relation to incident management and prevention.; Ensure staff are aware and effectively use the incident management system.

   Generated by qwen2.5:32b on 12 June 2026 from the published Performance Report. AI output — may contain errors; verify against the source document and the official findings above.

6. Site audit Performance ReportSep 1, 2022

   A site audit was conducted with this service on 30 August 2022 to 01 September 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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7. Accreditation decisionAug 6, 2021

   Following a site audit conducted on 25 May 2021 to 27 May 2021, the Commission made a decision on 06 August 2021 to re-accredit this service. The period of accreditation of the service will expire on 06 February 2023.

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8. Site audit Performance ReportMay 27, 2021

   A site audit was conducted with this service on 25 May 2021 to 27 May 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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9. Exceptional CircumstancesFeb 18, 2021

   During the COVID-19 pandemic, the Aged Care Quality and Safety Commission has temporarily modified our Regulatory Program, including the suspension of site audits to determine whether to accredit, not to re-accredit or vary the periods of accreditation for a service. In order to give effect to continuity of accreditation the Department of Health has, under Section 42.5 of the Aged Care Act 1997, made a decision to grant ‘exceptional circumstances’ to this service until 21 September 2021. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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10. Non-compliance updateDec 10, 2019

    Following an assessment contact conducted on 9-10 December 2019, the Commission made a decision on 9 January 2020 that the approved provider of the service is non-compliant with eleven requirements of the Quality Standards.

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11. Compliance updateNov 11, 2019

    Following an assessment contact conducted on 11 November 2019, the Commission made a decision that improvements have been made to the service to ensure that the Aged Care Quality Standards are complied with.

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12. Non-compliance updateAug 14, 2019

    Following an assessment contact conducted on 14 August 2019, the Commission made a decision that the approved provider of the service is non-compliant with 2 requirements of the Aged Care Quality Standards.

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13. AssessmentJan 18, 2018

    Following an audit we decided that this home met 43 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 21 March 2021.

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14. AssessmentMar 17, 2017

    This is a new home and is accredited for one year until 21 March 2018. We made the decision on 21 March 2017.

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No regulatory actions recorded.